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Patterns of Care in Neoadjuvant Chemoradiotherapy for Node-Positive Esophageal Adenocarcinoma.

ABSTRACT:

Background

The aims of this study were to examine the factors associated with use of neoadjuvant chemoradiotherapy (NCR) for patients with locally advanced esophageal cancer and to evaluate the effect of NCR on survival.

Methods

The 2004 to 2015 National Cancer Database was used to identify patients with cT1-4aN1-3M0 (stage II-IVA) esophageal adenocarcinoma who underwent esophagectomy. Patients were stratified by receipt of NCR. A multivariable logistic regression was performed to examine factors associated with NCR, and survival between the 2 groups was compared using a multivariable Cox model.

Results

Of 8076 patients meeting the study criteria, 1616 (20%) did not receive NCR and 6460 (80%) did. In a multivariable regression, factors associated with receipt of NCR were a later year of diagnosis, treatment in a high-volume center, and clinical stage III disease. Factors associated with nonreceipt of NCR were increasing age, comorbidities, and treatment in a Middle Atlantic, South Central, or Pacific state. Receipt of trimodality therapy was associated with improved survival compared with other or no perioperative therapies (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74-0.87).

Conclusions

Numerous personal-, demographic-, and treatment center-related factors account for variability in NCR for clinically node-positive esophageal adenocarcinoma, although neoadjuvant therapy was associated with a survival benefit. Further efforts are needed to identify reasons for these differences and design interventions to provide more equitable care for patients with esophageal cancer.

SUBMITTER: Raman V

PROVIDER: S-EPMC7669693 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceWhile neoadjuvant chemoradiation for esophageal cancer improves oncologic outcomes for a broad group of patients with locally advanced and/or node-positive tumors, it is less clear which specific subset of patients derives most benefit in terms of overall survival (OS).ObjectiveTo determine whether neoadjuvant chemoradiation based on esophageal adenocarcinoma histology has similar oncologic outcomes for patients treated with surgery alone when stratified by clinical nodal status.Design, setting, and participantsA retrospective analysis using the American College of Surgeons National Cancer Database from 1998 to 2006. Patients with esophageal adenocarcinoma histology and clinical stage T1bN1-N3 or T2-T4aN-/+M0 were divided into 2 treatment groups: (1) neoadjuvant chemoradiation followed by surgery and (2) surgery alone. Subset analysis within each treatment group was performed for clinically node-negative patients (cN-) vs node-positive patients (cN+) in conjunction with pathological nodal status. A propensity score-adjusted analysis, which included patient demographics, comorbidity status, and clinical T stage, was also performed.Main outcome and measuresThe primary outcome was 3-year OS. Secondary outcomes included margin status, postoperative length of stay, unplanned readmission rate, and 30-day mortality.ResultsA total of 1309 patients were identified, of whom 539 received neoadjuvant chemoradiation followed by surgery and 770 received surgery alone. Of the 1309 patients, 41.2% (n = 539) received neoadjuvant chemoradiation and 47.2% (n = 618) were cN+. Median follow-up for the entire cohort was 73.3 months (interquartile range, 64.1-93.5 months). The 3-year OS was better for neoadjuvant chemoradiation followed by surgery compared with surgery alone (49% vs 38%, respectively; P < .001). Stratifying based on clinical nodal status, the propensity score-adjusted OS was significantly better for cN+ patients who received neoadjuvant chemoradiation (hazard ratio, 0.52; 95% CI, 0.42-0.66; P < .001). In contrast, there was no difference in OS for cN- patients based on treatment (hazard ratio, 0.84; 95% CI, 0.65-1.10; P = .22).Conclusions and relevancePatients with cN+ esophageal adenocarcinoma benefit significantly from neoadjuvant chemoradiation. However, patients with cN- tumors treated with neoadjuvant chemoradiation plus surgery do not derive a significant OS benefit compared with surgery alone. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN- disease.